HLTH 2110 Week 6 Midterm Discussion Post Example

Week 6 Discussion: Belief or Structure?

Spanish-Preferring Latino Adults Screen for Colorectal Cancer at Half the White Rate: Why I Side With Cost and Access, and What Would Prove Me Wrong

The pattern: in national survey data from 2010, 62.0% of white adults reported current colorectal cancer screening, compared with 30.6% of Hispanic adults who preferred to answer in Spanish (Liss & Baker, 2014). The usual explanations split two ways. One says beliefs drive the gap: fatalism about cancer, embarrassment about the tests or a preference for not seeking care without symptoms. The other says structure drives it: lack of insurance, no usual source of care, cost, time off work and language barriers in the health system.

I am siding with the structural explanation. My reason is that when obstacles are removed, screening rises sharply in exactly this population. In a trial at community health centers where 87% of patients were Latino, 83% preferred Spanish and 77% were uninsured, patients who were mailed a free home test with simple instructions and a prepaid return envelope, plus automated reminders, completed annual screening at 82.2%, compared with 37.3% in usual care (Baker et al., 2014). These patients had all completed a home test the year before, so they were not opposed to screening; the trial shows that even willing patients fall away when the next step is left to them. In another safety-net trial, mailing a test kit raised screening above usual care (Gupta et al., 2013). If beliefs were the main barrier, a mailed kit would not change them, yet participation more than doubled in the first trial.

Here is what would count against my position. If the gap remained large among Spanish-preferring adults who had insurance, a usual source of care and similar incomes to white adults, then structure could not be the main story. Liss and Baker (2014) tested this. After adjusting for socioeconomic status and access, the gap narrowed but did not close: Spanish-preferring Hispanic adults were still about 24% less likely to be screened (relative risk 0.76). So structure explains part of the pattern and leaves part unexplained.

I take the remaining gap seriously, and I treat the belief explanation as a hypothesis that might account for it, not as a prejudice. But the remaining gap might also reflect structural factors the survey did not measure, such as whether clinicians recommended screening in Spanish or whether the clinic offered a home test at all. Before I would accept belief as the explanation for the residual, I would want a study that measured those factors too.

Question for the board: if a mailed kit works this well, does it matter which explanation is right, or only which intervention works?

Reply to Andre

Andre, you argued that cultural beliefs explain the gap, citing studies where Latino patients reported embarrassment about colonoscopy. I think that evidence is real but may be about a specific test. Embarrassment about colonoscopy would not prevent someone from using a home stool test, and Baker et al. (2014) found that most patients offered one used it. Does your explanation hold for screening in general, or mainly for colonoscopy?

Reply to Priya

Priya, I agree with your point that the two explanations are not exclusive, and I think Liss and Baker's (2014) adjusted result supports you: access explained part of the gap and something else explained the rest. My question is about your proposed study. You suggested surveying beliefs among unscreened adults. Would you also measure whether their clinicians had recommended screening? Without that, a belief finding might be picking up the effect of never being asked.

References

Baker, D. W., Brown, T., Buchanan, D. R., Weil, J., Balsley, K., Ranalli, L., Lee, J. Y., Cameron, K. A., Ferreira, M. R., Stephens, Q., Goldman, S. N., Rademaker, A., & Wolf, M. S. (2014). Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: A randomized clinical trial. JAMA Internal Medicine, 174(8), 1235-1241. https://doi.org/10.1001/jamainternmed.2014.2352

Gupta, S., Halm, E. A., Rockey, D. C., Hammons, M., Koch, M., Carter, E., Valdez, L., Tong, L., Ahn, C., Kashner, M., Argenbright, K., Tiro, J., Geng, Z., Pruitt, S., & Sugg Skinner, C. (2013). Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: A randomized clinical trial. JAMA Internal Medicine, 173(18), 1725-1732. https://doi.org/10.1001/jamainternmed.2013.9294

Liss, D. T., & Baker, D. W. (2014). Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: The contribution of socioeconomic status and access to care. American Journal of Preventive Medicine, 46(3), 228-236. https://doi.org/10.1016/j.amepre.2013.10.023